Who Documented the Service?
Q. In our Department we use a single progress note form that is completed by everyone who sees the patient on that day. The nurse or MA completes the intake information at the top of the form, the resident completes certain other components of the documentation, and I complete my portion (typically assessment and plan and parts of the physical exam). Since no one signs the form but me, I am taking responsibility for all of the documentation on the form. I don’t see why this would be a problem or why I would need to add a linking statement on this type of documentation. A. When multiple people complete documentation on the same form the documentation must clearly indicate who completed each aspect of the documentation and when that documentation was completed (i.e., it must be signed and dated). The fact that a physician signs below all of the other documentation and pulls all of the documentation together into a single note does not change the need for each documenter to identify the p
